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Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs
© Ogawa et al.; licensee BioMed Central Ltd. 2013
Received: 25 July 2013
Accepted: 28 October 2013
Published: 1 November 2013
Traumatic hemothorax commonly occurs accompanied by organ damage, such as rib fractures, lung injury and diaphragm rupture. Our reported patient was a 61-year-old man who fell down from a stepladder about 1 meter in height, resulting in a heavy blow to the left abdomen. He consulted a clinic because of left chest pain the next day and was transported to the emergency center of our hospital on diagnosis of hemothorax with hemorrhagic shock.
On computed tomography scanning with contrast medium, left hemothorax without rib fracture, diaphragm rupture or obvious organ injury was evident. We found only bleeding to the thoracic space from a branch of the left inferior phrenic artery without involvement of the abdomen. The patient underwent percutaneous angiography and embolization for hemostasis, and subsequently thoracotomy in order to check the active bleeding and remove the hematoma to improve respiratory. As thoracotomy findings, we found damage of a branch of the left inferior phrenic artery to the thoracic space without diaphragm rupture, and sutured the lesion. Such active intervention followed by surgical procedures was effective and should be considered for rare occurrences like the present case. We must consider not only traumatic diaphragm rupture, but also vascular damage by pressure trauma as etiological factors for hemothorax.
Traumatic hemothorax commonly occurs immediately after trauma, accompanied by organ damage, such as rib fracture, lung injury and diaphragm rupture. Importantly, hemothorax with diaphragm rupture is reported to be generally not fatal, but the mortality rate reaches 18-50% when complicated with great vessel injury and involvement of major organs. In such cases it requires immediate diagnosis and medical intervention.
We here report a rare case in which occult hemothorax occurred without organ injury.
A 61-year-old man fell down from a stepladder about 1meter in height and suffered a heavy blow to the left abdomen during performance of carpenter’s work. Next day, he went to a clinic because of continued left chest pain. In a chest X-ray, fluid effusion in his left thoracic space without pneumothorax was noted and he was transported to the emergency center of our hospital based on diagnosis of hemorrhagic shock with hemothorax.
The postoperative course was uneventful and he could be discharged from hospital without complications on the 6th day after thoracotomy.
This is very rare case of hemothorax without multiple organ damage after brunt trauma, unlike any prior example that we could find in the literature. It was previously reported that hemothorax is produced when blunt trauma causes dome top lesions to the diaphragm from the abdominal side in cases of diaphragm rupture[1, 2]. Lateral collisions, which are three times more common, cause ipsilateral tears secondary to thoracic distortion and shearing. In this case, there was no diaphragm rupture, but it was thought that intraphrenic artery damage resulted because a remarkable pressure gradient was applied to the diaphragm. Traumatic diaphragm injury accounts for 0.8 ~ 3.3% of blunt trauma cases[2, 3], and when restricted to traffic accidents, the frequency of the diaphragm rupture is relatively rare at 1-5%[2, 4]. In fact, the reason for traumatic diaphragm injury was previously reported to be traffic accidents in about 70% of cases, and, interestingly, left sided rupture is three times more common than on the right[3, 5]. Cadaveric studies have demonstrated that the pressure required to rupture the left hemidiaphragm is consistently lower than that on the right, due to the relative weakness on the left from the lumbocostal trigone to the point of embryological fusion.
Since patients with traumatic lesions and hemorrhagic pleural effusion usually have multiple bleeding sources, contrast-enhanced CT is generally considered necessary to identify the bleeding points, document their anatomic relationships, and detect extravasation of contrast agent or pseudoaneurysms[2, 7, 8].
Carrillo et al. stated that the morbidity associated with thoracotomy, coupled with the frustratingly low likelihood of finding the source of hemorrhage in some patients, makes selective angiography and transcatheter embolization a less invasive, more accurate, and reliable method for treatment. Another problem is disorder of the clotting system, which is generally induced by massive hemorrhage and may develop into consumption coagulopathy in patients with multiple bleeding sources. This potentially lethal disorder is difficult to treat and results in uncontrollable diffuse bleeding.
In conclusion, enhanced CT scan and IVR are effective procedures for identifying the origin of bleeding into the thoracic space without diaphragm rupture or obvious organ injury. In addition, conclude that active intervention, such as surgical procedures, may be necessary for rare occurrences like the present case. We must consider not only traumatic diaphragm rupture, but also vascular damage by pressure trauma as etiological factors for hemothorax.
Written informed consent was obtained from patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors thank Dr. Fumie Kashimi, Department of Emergency Center, Kitasato University, School of Medicine, Kanagawa, Japan, for clinical support and IVR, as well as Dr. Malcolm A. Moore for linguistic assistance.
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